Failure to Secure Facility Access and Protect Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s personal property and to follow its own policies for documenting and investigating misappropriation of resident belongings. A resident admitted with diabetes mellitus, malignant neoplasm of the endocrine pancreas, muscle weakness, difficulty walking, and moderate to severe depressive symptoms had intact cognitive skills but required moderate to total assistance with ADLs. Review of the medical record as of 2/17/2026 showed no personal inventory list of the resident’s belongings, and the Medical Records Director confirmed that the resident’s personal belongings were not inventoried or documented upon admission, contrary to the facility’s Personal Property policy requiring such documentation. The report describes an incident in which an unhoused individual entered the facility without staff knowledge and stayed and slept in an unassigned bed in the same room as the resident. The resident’s family member reported that the resident pressed the call light multiple times after discovering the individual sleeping in the room and acting strangely, but no staff responded for a while. The family member stated that the resident felt terrified and unsafe, and that the resident’s mobile phone was discovered missing that morning and reported to staff. A LVN stated she noticed the unhoused individual in the resident’s room early in the morning, initially thought there was no resident assigned to that bed, and questioned the individual, who claimed to have checked in and was holding a mobile phone and a plastic grocery-type bag. The LVN escorted the individual out but did not document the incident, did not report it to management or staff, and did not assess the resident. She did not know how long the individual had been in the room or what he did while there, and reported that the CNA had also seen the individual and assumed he was a new resident. The DON stated she was informed that a person with no business in the facility had gained access and stayed in a bed in the resident’s room, that the front door was broken and not closing and locking properly, and that the resident’s mobile phone went missing after this access. The DON confirmed there was no documentation of the incident, no assessment of the resident after the incident, and no documentation of the resident’s personal belongings inventory, despite facility policies requiring inventory of belongings and complete documentation and investigation of any misappropriation of resident property.
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